ltd process

Long-term disability (LTD) insurance can provide a portion of lost income in the unfortunate event you become disabled and unable to work.  Most people obtain LTD insurance as an employee benefit through their employment along with other employee benefits like health insurance, dental, vision, and other benefits.  These cases are usually governed by a federal statute called the Employee Retirement Income Security Act of 1974, the federal ERISA statute, which governs employee benefit plans, except for people who work for government and church employers, which are exempt from the ERISA statute.  Some employers pay the premiums for their employees’ LTD insurance, some require their employees to pay the premium, and some provide a base LTD benefit with a buy-up the employee can pay to obtain a higher benefit level. It may surprise you to learn that disability insurance companies often deny people who make claims on LTD policies.  The LTD process itself can be long and confusing and sometimes seems as if it were designed to make claimants give up and walk away — and many people do.  Here’s what happens during the LTD process and the steps typically taken by the parties to an LTD claim.

Long-Term Disability Application 

An LTD claim begins with an application for benefits, generally a three-part form consisting of an Employee Statement you complete, an Employer Statement your employer completes, and an Attending Physician Statement for your doctors to complete (also called an APS.  Always make copies of the APS, since more treating physicians certifying your disability is almost always better for your claim than just one).  After your LTD application is filed, the insurance company will review the application along with any medical evidence you submit along with your job description and the LTD policy to determine if they agree you are disabled and entitled to benefits under the policy.  

Long-Term Disability Approval 

Sometimes the disability insurer reviews your application and medical evidence and concludes you are disabled, that no other impediment to payment of benefits exists, and approves your LTD claim. Congratulations!  You will generally receive a past-due LTD check from the end of your Elimination Period to the date of approval, and begin receiving monthly benefits from the disability insurance company.  From time to time the disability insurance company will send you an updated APS to give your doctor(s) to certify that you remain disabled and will require updated medical records for the same reason.  Generally, ERISA LTD policies pay for 24 months of disability from your own occupation, after which you must be disabled from any occupation to continue to receive LTD benefits.  

Long-Term Disability Denial

Sometimes the disability insurance company will deny your LTD claim on the basis that you aren’t entitled to benefits due to one or several factors in the policy, such as a pre-existing medical condition, or because the elimination period (the time you must be disabled before LTD benefits are payable) hasn’t been met, or based on other factors the insurer claims keep you from being eligible for benefits.  The administrator may or may not have a nurse or doctor review your medical records.  If the administrator determines your impairment doesn’t preclude you from being able to perform your occupation, or if they determine you are not eligible for benefits due to some other basis in your policy, the administrator will deny the disability application.  ERISA administrators also deny LTD applications if they don’t receive all the forms or paperwork they need.  If the insurance company denies the LTD application, they will state towards the end of the letter the next steps or options you have with regards to an appeal.

Long-Term Disability Appeal  

If your long-term disability application was denied, you now have the right to appeal the denial.

This is the point where we recommend you give us a call to see if we can help!

Clients often come to us while still in the administrative process with the insurance company.  This means the client still has at least one more appeal to the insurance company to review the medical evidence and make a decision to overturn the denial.  With respect to cases governed by the ERISA statute (the Employee Retirement Income Security Act of 1974) it is an excellent idea to contact an attorney upon receiving a denial from a disability insurer because that allows the disability insurance attorney to gather evidence in support of your appeal while the file is still open.  All evidence for an ERISA case under what is called the rational basis standard of review usually closes when a disability insurer makes a final decision to deny the insured’s final appeal.  Cremeens Law Group PLLC has helped many clients obtain an administrative reversal of a disability insurer’s denial of their claim for benefits without having to go to court.

The denial letter will list how much time you have, or the deadline, to submit your appeal, which is typically 180 days from the date of the denial or the date the denial letter was received.  While a simple letter stating that you appeal is theoretically enough to start the appeal process, our office would do much more than that to boost your claim and give you a better chance of winning the appeal.  When an appeal is submitted, the insurance company will have someone in their appeals department review the entire claim from the beginning, including any new information that you submitted when you filed the appeal.  They will usually have a doctor or doctors review the medical records and render an opinion on your ability to work.  Oftentimes, the doctor/s will specialize in the field that your medical symptoms belong to.  If the claim is denied at this point, some insurance companies offer two levels of appeal.  If there is another level of appeal, this step is duplicated the same way, only a different person will review the file on the next appeal.  If the insurance company offers only one level of appeal, and they deny the claim, the denial becomes a final denial or final decision.

What Happens On A Final Denial?

When a disability insurance company denies all available appeals, this results in a final denial at the administrative level, or what is called exhaustion of administrative remedies.  If you receive a final denial from the disability insurance company, this is the equivalent of the insurance company telling you, “We are done working with you and we are not going to pay.  If you want anything further done on this, sue us.”  When a claim is completely denied, the claimant can file a lawsuit against the insurance company.  The plaintiff will have to see that the insurance company is served with a complaint and is notified they are being sued, to which they will respond, acknowledging they are being sued, and the court will then issue a case management order that lists a calendar of events that will happen in the case.  When you file a lawsuit against the insurance company, the case can be concluded by winning, losing, or settling the case.  Although rare, there are also times when a case may be remanded back to the administrative level, which results in your claim being placed somewhere back in the timeline of the processes mentioned above.

Cremeens Law Group PLLC can help people who need assistance with filing a long-term disability application, filing an appeal on a disability insurance denial, or filing a lawsuit against an insurance company after receiving a final denial.  Cremeens Law Group PLLC also offers appellate representation in the Eleventh Circuit Court of appeals, often giving clients another chance to win.  

As mentioned earlier, it’s better to contact us as soon as possible if you receive a denial on your application, however, if you’re just finding out about us, regardless of where you are in the process, give our office a call so we can look at the facts and circumstances surrounding your situation and see if we can offer assistance to get you the disability benefits you deserve.  The consultation is free, so call us at 813-839-2000 (813-839-2000).